A nurse is assessing a 10-month-old baby's anterior fontanel and finds it slightly depressed; the fontanel measures 2 inches (5.08 cm). What conclusion and action are most appropriate?
A.
Delayed closing; alert health-care provider.
B.
Fontanel is closing; document findings.
C.
Large for age; assess for Down's syndrome.
D.
Sign of dehydration; assess fluid status.
ANS: D
The anterior fontanel remains open until 12-18 months of age. The normal size is 0.4-2.8 inches (1-7 cm). A depressed fontanel is a sign of possible dehydration, and the nurse should assess for other signs of fluid status. The closing is not delayed, it is not overly large, nor should it be closing as part of normal growth and development.
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